The Psychodynamic Diagnostic Manual (2017) avoids the pitfalls of the DSM by conceptualizing disorders as holistic conditions that have both their strengths and weaknesses. The PDM describes conditions along several continuums—behavioral symptoms, thought and feeling patterns, the subjective experience of the person and—especially important for therapists—how the therapist is likely to experience sitting with someone with each disorder. Disorders are seen not as separate, discrete conditions, but as part of a tapestry which recognizes the prevalence of comorbidity and the fact that very few mental disorders exist in a pure state. The PDM also views disorders on a continuum that may stretch from normal to severely pathological.
Prevalence of anxiety disorders. Women are twice as likely as men to have anxiety disorders, with the exception of obsessive-compulsive disorder and possibly social anxiety. This is in concordance with DSM and other epidemiological estimates of incidence.
Reasons for the gender disparity may include hormones, cultural pressures on women to meet the needs of others before their own, and women feeling less shame about reporting anxiety. As with so many other disorders, the biological view of anxiety disorders has been gaining currency, which obscures the fact that the interplay of biology, emotions and cognitions is an inextricable tangle of cause and effect. In the PDM view, anxiety involves cognition and emotional and physical experience. Psychodynamic psychotherapy attempts to integrate all these causal factors.
The PDM addresses the growing trend to view many disorders, including anxiety disorders, as fundamentally biological in origin. In its discussion of epigenetics, citing Schore (2003), it points to:
the utility of the epigenetic model for the development of self-regulation and executive function, with the quality of early caregiving as “a key mediator of links between children’s exposure to adversity (e.g., poverty, abuse, trauma) and subsequent physiological, neurobiological and psychological development. In this process, stress hormone levels constitute a primary mechanism through which cognitive and social-emotional development in early childhood is shaped by experience, with specific reference to the development of neural systems critical to self-regulation, including attention, emotion and working memory. The epigenetic model has provided a basis for studies on the intergenerational transmission of individual differences in stress reactivity and resilience. The issue is not one of inheritance, but rather the mode of inheritance.
Epigenetic research indicates that chronic exposure to adversity actively shapes the physiological and behavioral developments that are adaptive to that context. Personality adaption within adversity and compromised caregiving results in short-term beneficial adaptations but harmful long-term consequences. A central implication of these tradeoffs is that self-regulation can be altered; that is, the shaping of development by experience offers opportunities for repair and reversal. From a developmental psychobiological perspective, experiential and biological influences are highly intertwined (p 505).
PDM conceptualization of anxiety disorders. The PDM conceptualizes General Anxiety Disorders, and in fact, many of the other anxiety disorders, as a personality pattern/disorder rather than a discrete syndrome. In doing so, it views anxiety disorders not as symptoms to be addressed but as expressions of underlying personality patterns and unconscious processes that should, more than the behavioral manifestations, be addressed in psychotherapy. It defines anxiety as “fear in the absence of obvious danger…in which the fight-flight-freeze system is activated in the expectation of disaster ( p 164).” Anxiety may be conscious or unconscious. Among the different types of anxiety are separation anxiety—the fear of losing a loved object; castration anxiety—a fear of losing a body part, usually but not always the genitals; moral anxiety—the fear of what may happen to someone who transgresses their own values; annihilation anxiety—the fear of a catastrophic invasion, accident, or attack by someone or by some force; fragmentation anxiety—the fear of one’s self or personality coming apart of disappearing; and persecutory anxiety—the fear of one’s self or loved ones being harmed by others.
This wide-ranging list of anxieties can easily be seen as what becomes in DSM taxonomy other disorders. For example, persecutory anxiety at first seems the same as Paranoid Personality Disorder. However, the PDM does draw important distinctions between many anxious personality disorders and several seemingly similar disorders. It notes that the mere presence of anxiety, even when it is overwhelming, does not necessarily lead to a diagnosis of Anxious Personality Disorder. For example, someone with an anxiety-driven disorder may become so filled with dread that the defenses they employ, such as projection and denial, become the central fact of their functioning, replacing the conscious experience and deliberate attempts to deal with the anxiety itself. In such instances, the diagnosis of paranoid personality disorder would be more appropriate. Likewise, the person with the anxious personality structure is chronically aware of their anxiety and usually experience a free-floating, global sense of anxiety, often with no clear idea of what frightens t them, whereas the hysterical, phobic, or obsessional person whereas the hysteric, obsessional or phobic person has a clearer idea of what they’re anxious about. An important distinguishing characteristic, therefore of Anxious Personality Disorder, is that people are aware of their anxiety, not the object of their anxiety.
One of the realities of therapy which the PDM addresses, while the DSM does not, is that therapists primarily diagnose from their own feelings, intuitions and experiences and turn to the symptom checklists secondarily. Therefore, it’s important to understand countertransference reactions caused by people with anxiety personality disorders. “Countertransferential experiences may vary widely,” it notes. “Clinicians may feel empathic involvement, parental countertransference, and the needs to reassure their anxious patients. Or, they may feel overwhelmed by the anxiety…especially in patients with severe personality disorder or psychosis. In response, they are at risk of defensively disengaging themselves from the relationship. It is common to experience frustration when treating individuals with anxiety or phobias. (p 166-67).” Clinicians may also prematurely recommend medication, in a misguided attempt to quiet both the client’s and their own anxiety.
Although the PDM, as its name implies, is psychodynamically oriented, it notes the usefulness of other treatments. Treatments such as systematic relaxation training, meditation, mindfulness and other cognitive-behavioral techniques are considered helpful adjuncts to treatment, in order to calm and focus clients enough so that the deeper psychoanalytic exploration can take place and so that the process of understanding, naming, and mastering previously unformulated emotional states can occur. Again, the focus of treatment is not, as an end in itself, to quell the distressing symptom.
References
Interdisciplinary Council on Developmental and Learning Disorders (2017). The Psychodynamic Diagnostic Manual. New York: Guilford Press.